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LETTERS TO EDITOR
Year : 2018  |  Volume : 19  |  Issue : 1  |  Page : 32-33
 

Pectoral nerves-II block for chronic resynchronization therapy device placement: A novel approach


Department of Anesthesia., Care Hospitals, Hyderabad, Telangana, India

Date of Web Publication22-May-2018

Correspondence Address:
Dr. Somita Christopher
Flat No. 504-B, Amsri Central Court, Near Lancer Lines, Secunderabad - 500 003, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/TheIAForum.TheIAForum_39_17

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How to cite this article:
Christopher S, S Gopal T V. Pectoral nerves-II block for chronic resynchronization therapy device placement: A novel approach. Indian Anaesth Forum 2018;19:32-3

How to cite this URL:
Christopher S, S Gopal T V. Pectoral nerves-II block for chronic resynchronization therapy device placement: A novel approach. Indian Anaesth Forum [serial online] 2018 [cited 2019 Sep 22];19:32-3. Available from: http://www.theiaforum.org/text.asp?2018/19/1/32/232907




Sir,

Chronic resynchronization therapy device (CRTD) placement is mainly done in highly specialized hospitals. In most cases, the procedure is carried out under local anesthesia as these patients are at a very high cardiac risk. There are insufficient data regarding the degree of pain associated with the procedure. Pectoral nerve block (PECS-II) is a relatively easy and new block, which was initially introduced by Blanco [1] for postoperative analgesia after breast surgery. Here, we present a case of successful application of PECS block for CRTD implantation.

A 72-year-old male, with hypertrophic obstructive cardiomyopathy and paroxysmal atrial fibrillation was posted for CRTD placement. He was also a known case of hypertension, diabetes and chronic kidney disease. Transthoracic echocardiography showed ejection fraction – 70%, hypertrophic obstructive cardiomyopathy, mitral systolic motion, left ventricular outflow gradient of 87 mmHg at rest and a dilated left atrium. His coronary angiogram revealed a branch vessel disease for which he was placed on medical management. The patient was assigned as American Society of Anesthesiologists physical status III and placement of CRTD device was planned under PECS-II block and mild sedation. In the cardiac catheterization laboratory, the patient was placed supine with 30° head up and left arm abducted at 90°. Basic monitoring included noninvasive blood pressure, electrocardiography, and pulse oximetry. A high-frequency linear probe was placed in the parasagittal plane adjacent to the coracoid process at the level of the second rib. Pectoralis major and minor muscles were identified along with pectoral branch of the thoracoacromial artery which usually runs between the pectoralis major and minor muscles. The probe was then slided laterally and inferiorly to identify the serratus anterior muscle at the level of fourth rib [Figure 1]. A volume of 20 ml of 0.375% bupivacaine was injected in the interfascial plane between pectoralis minor and serratus anterior muscles and 10 ml between the pectoralis major and minor muscles [Figure 2]. The patient was given 1 mg midazolam and 25 micrograms fentanyl intravenously for sedation. The cardiologist was requested to infiltrate the skin with 5 ml of 2% xylocaine at the incision site. The procedure lasted for 2 h. Throughout the procedure, the patient was pain-free and comfortable. The patient also remained pain-free for 12 h after the procedure.
Figure 1: Position of the probe

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Figure 2: 1 – Injection between Pmi and SA. 2 –Injection between PM and Pmi. PM: Pectoralis major, Pmi: Pectoralis minor, SA: Serratus anterior

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Cardiac resynchronization therapy in the recent past has revolutionized the management of heart failure.[2] Inability to provide adequate acute perioperative pain can lead to chronic postsurgical pain [3] PECS block is a simple technique that can provide good pain relief intra as well as postoperatively. PECS block was initially introduced by Blanco et al.[4] as a novel technique for providing analgesia after breast surgery, but extended indications include analgesia after wide local excision, axillary clearance, breast expander insertion and anterior thoracotomy. The nerves involved are intercostal nerves of T2–T6 which lie in the plane between pectoralis minor and serratus anterior muscle and the lateral and medial pectoral nerves which run in the plane between the pectoralis major and minor muscles. With the use of ultrasound, we could decrease the dose of the local anesthetic agent by depositing the drug accurately at the desired place. Another advantage of this block is an extension of analgesia in the postoperative period. Anderson et al. recently presented a summary of their research about analgesia after cardiac electronic devices (CED) implantation at the 15th World Congress on pain.[5] They found that only 48% of the patients received analgesia after CED implantation and also concluded that pain after CED implantation is underated. We have also given this block in four other patients posted for CRTD implantation with similar results. We recommend the use PECS-II Block in high-risk patients undergoing CRTD implantation for providing analgesia.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Blanco R. The 'pecs block': A novel technique for providing analgesia after breast surgery. Anaesthesia 2011;66:847-8.  Back to cited text no. 1
[PUBMED]    
2.
Gadler F, Valzania C, Linde C. Current use of implantable electrical devices in Sweden: Data from the Swedish pacemaker and implantable cardioverter-defibrillator registry. Europace 2015;17:69-77.  Back to cited text no. 2
[PUBMED]    
3.
Sansone P, Pace MC, Passavanti MB, Pota V, Colella U, Aurilio C, et al. Epidemiology and incidence of acute and chronic post-surgical pain. Ann Ital Chir 2015;86:285-92.  Back to cited text no. 3
    
4.
Blanco R, Fajardo M, Parras Maldonado T. Ultrasound description of pecs II (modified pecs I): A novel approach to breast surgery. Rev Esp Anestesiol Reanim 2012;59:470-5.  Back to cited text no. 4
[PUBMED]    
5.
Anderson RH, Cox FJ, Jaggar SI. Analgesia Provision for Cardiac Device Implantation- an Unrecognised Need. 15th World Congress on Pain; 6-11 October, 2014. Buenos Aires, Argentina; 2014. Available from: http://www.docplayer.net/44253580-15th–world-congress-on-pain.html. [Last accessed on 2017 Mar 29].  Back to cited text no. 5
    


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